Survival of Patients on ART in the Test-and-Treat Era: A Retrospective Cohort Study in Maputo, Mozambique

Abstract

Introduction: As the 2030 global target for ending AIDS approaches, Mozambique continues to face significant challenges in HIV response. Although the test-and-treat strategy (TTS) has been in place for nearly a decade, survival outcomes remain suboptimal in many settings. We estimated the effect of TTS on survival among ART patients and identified associated factors in Maputo. Method: We conducted a retrospective cohort study with two arms—BTT (2013-2016) and ATT (2017-2020)—using routinely collected data from ART patients aged 15 - 49 years across 12 health facilities, in Maputo. Data were extracted from the electronic patient tracking system (ePTS/Open MRS). Survival was estimated using Kaplan-Meier methods; predictors of death were identified via Cox proportional regression, and population attributable fraction (PAF) was calculated to assess the impact of TTS. Results: Among 16,968 patients on ART (9036 BTT; 7932 ATT), 6258 HIV-related deaths occurred over 236,754 person-years follow-up. Mortality rate was lower in the ART arm (24.5 per 1000 person-year), with longer median survival time (50.6 months), than in the BTT arm (28.1 per 1000 person-year) in 43.1 months. Test-and-treat strategy had a protective effect against mortality (HR = 0.84%), with an adjusted PAF for the exposure of 7.3%. Increased hazard of death was consistently associated with older age, male sex, suburban residence, second-line ART, HIV-TB co-infection, advanced WHO stage, and low BMI. Conclusions: Test-and-treat strategy improved survival among ART patients in Maputo, strengthening its relevance for Mozambique and other low-income, high-HIV-burden countries. Future studies should examine its effects on subgroups, undocumented mortality and self-transfer.